What Is the Big Deal About Student Supervision?

JRCERT Update

What Is the Big Deal About Student Supervision? Stephanie Eatmon, EdD, R.T.(R)(T), FASRT Laura Aaron, PhD, R.T.(R)(M)(QM)

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t some point, each of us was a student in clinicals. As we look back on that time, we probably remember many different experiences during our clinical rotations. And as students, we likely made a fair number of mistakes — a normal and expected part of the learning process. Each of us learned through the hands-on experience of the clinical environment. The professionals we worked with as students were role models who helped us learn the art and science of our profession. Each program and institution we attended for clinicals has policies and procedures that students had to follow. The same is true today. Some technologists talk about being “on call” as a student, and they recount stories of being called out in the middle of the night to do examinations — sometimes without a technologist present. As a student, they were expected to function as a technologist. Some might argue that being thrown into an experience to either sink or swim was an excellent way to learn. However, patient safety may be compromised for this method of student learning. Sure, the student might figure out how to do the exam on his or her own, but the patient could face numerous repeats resulting in higher doses of radiation. In this scenario, student learning also is hit or miss depending on the student’s ability to learn from errors or understand the importance of actions he or she did or did not take. The student does not have the same experience base to apply the problem-solving or

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critical-thinking techniques used by a technologist who understands how to adapt to changing situations while still adhering to ALARA. Patient safety is paramount in the health care setting. Each of us is responsible for making sure that we remain up-to-date with technology and best practices for our patients. Students are learning to become competent health care professionals. They are expected to, and will, make mistakes during their education. As technologists working with students, we try to ensure that patient safety is not compromised at the expense of learning. It is a delicate balance to let students work with patients and not take over each time they are close to making a mistake. Luckily, programmatic accreditation addresses student supervision and does not allow students to function unsupervised, but what exactly are the rules for student supervision? In the Joint Review Committee on Education in Radiologic Technology (JRCERT) Standards for an Accredited Educational Program in Radiography, 3 objectives address supervision (see Box).1 A common question that arises when supervising radiography students involves indirect supervision for procedures on which the student has achieved competency. The phrase “immediately available” often is questioned. If a student is on a portable, operating room, or emergency department rotation, a technologist must be immediately available to supervise the student. This means that the technologist must be nearby (ie,

RADIOLOGIC TECHNOLOGY, November/December 2012, Volume 84, Number 2

JRCERT Update Eatmon, Aaron

Box JRCERT Radiography Objectives That Address Supervision 4.4 − Assures that medical imaging procedures are performed under direct supervision of a qualified radiographer until a student achieves competency. The JRCERT defines direct supervision as student supervision by a qualified radiographer who:  Reviews the procedure in relation to the student’s achievement.  Evaluates the condition of the patient in relation to the patient’s knowledge.  Is physically present during the conduct of the procedure.  Reviews and approves the procedure and/or image. 4.5 − Assures that medical imaging procedures are performed under the indirect supervision of a qualified radiographer after a student achieves competency. The JRCERT defines indirect supervision as the supervision provided by a qualified radiographer immediately available to assist students regardless of the level of student achievement. “Immediately available” is interpreted as the physical presence of a qualified radiographer adjacent to the room or location where a radiographic procedure is being performed. This availability applies to all areas where ionizing radiation equipment is in use on patients. 4.6 − Assures that students are directly supervised by a qualified radiographer when repeating unsatisfactory images. A qualified radiographer must be physically present during the acquisition of a repeat image and must approve the student’s procedure prior to re-exposure.

adjacent to the room or location where a radiographic procedure is being performed) and available to assist the student quickly. Being available by phone, pager, or other communication is not considered “immediately available.” In the JRCERT Standards for an Accredited Educational Program in Radiation Therapy, objective 4.4 addresses supervision.2 To be in line with the standard, the program “Assures that all radiation therapy procedures are performed under the direct supervision of a qualified practitioner.” A qualified practitioner, credentialed medical physicist, or licensed radiation oncologist must supervise students directly during all aspects of the procedure. For departments affiliated with a JRCERTaccredited educational program, there are strict standards regarding student supervision. In radiography, the radiographer is responsible for reviewing the procedure ordered with the student to ensure the student has attained the knowledge and skills necessary to perform the procedure. In addition, the radiographer directly supervises the student while assessing the patient’s condition in relation to the procedure. Throughout the procedure, the radiographer is with the student to ensure an optimal image is obtained using the lowest exposure dose possible. Once the student has demonstrated competency for completing a particular procedure, the

radiographer is able to supervise the student indirectly. Although the radiographer no longer has to be in the same room as the student, he or she must stay in close proximity in case help is needed. Any time a student must repeat a radiograph, whether or not he or she has completed a competency on that exam, the student must have direct supervision. This practice provides the opportunity for the student to learn from errors and for the radiographer to assess and instruct the student in critical thinking and problem solving, thus helping to prevent a repetition of errors. In radiation therapy, a student must be supervised directly at all times. Observing the student from the monitor or entering the room after the student has set up the patient to “check it out” is not acceptable. When the patient enters the treatment or simulation room, the therapist must accompany the student and patient. The student may perform the procedure, but the therapist is present and available, watching to assess student skill and accuracy. These standards protect the practitioners, students, and patients. They also provide students the opportunity to learn from their errors while eliminating the patient’s exposure to excessive radiation. To ensure these standards are followed, educational programs hold both the student and the professional accountable to the rules. Students who perform procedures without


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JRCERT Update What Is the Big Deal About Student Supervision?

the proper level of supervision are penalized and can face severe consequences. One thing to remember is that the JRCERT is a programmatic accreditor, and programs accredited by the JRCERT must abide by the standards. These standards are in place to protect students as well as patients. Institutional accreditation does not provide programmatic standards related to student supervision. Therefore, programs not accredited by the JRCERT, but housed in an accredited institution, are not accountable for student supervision or student safety based on guidelines from their institutional accreditation. Over the past 10 years, the public has seen an increase in exposure dose because of the increase in technology and an increase in the volume of exams. 3 Keeping the exposure doses at ALARA levels is a professional value that must be adhered to daily and passed along to the student. The JRCERT is dedicated to upholding those professional values while ensuring patient and student safety. The outcomes of direct supervision go well beyond patient and student safety. In our profession, there is much more to completing a procedure than correct positioning, setting exposure techniques, and monitoring unit settings. Combined with technical competency are the essential competencies of caring, compassion, and educating the patient. Patients should feel comfortable and understand the procedure they are about to undergo. All patients should feel comfortable enough to ask questions and believe they are in the hands of a professional. A student who completes the technical portion of a procedure, but who does not focus on patient needs, does a disservice to the patient and the profession. Direct supervision gives the practitioner an all-encompassing view of the student’s abilities with the opportunity to provide feedback on all aspects of the procedure. Radiography students who have had this level of clinical instruction and who have demonstrated competence in both the technical and patient care aspects likely will be more confident moving to indirect supervision. Not only do the JRCERT standards promote patient and student safety, but when followed, they also help to provide a better overall education. Practitioners who work 1-on-1 with students in the clinic are the backbone of the profession. Not only are they the role models, but they also determine the future 198

of the profession by their daily actions and attitudes. Students aspire to be as professional and competent as their clinical instructors. Graduates often learn how to be clinical instructors by modeling the instructors who interacted with them as students. Our profession owes these practitioners a deep appreciation for the education and role modeling they provide the students, thereby promoting the profession now and in the future. The benefits of establishing standards for supervision are clear — fewer repeats and less exposure for the patients and enhanced learning opportunities for the students. When students receive a solid didactic and clinical education, they graduate to become true professionals of whom we can all be proud. It does “take a village” to properly educate those who have chosen our profession. Stephanie Eatmon, EdD, R.T.(R)(T), FASRT, is the program director of the radiation therapy program at California State University, Long Beach. She can be reached at [email protected]. Laura Aaron, PhD, R.T.(R)(M)(QM), is the director and graduate coordinator of allied health at Northwestern State University in Shreveport, Louisiana. She is also a member of the Radiologic Technology Editorial Review Board. She can be reached at [email protected].

References

1. Joint Review Committee on Education in Radiologic Technology. Standards for an accredited educational program in radiography. www.jrcert.org/sites/jrcert/uploads/docu ments/2011_Standards/Standards_2011-Radiography.pdf. Effective January 1, 2011. Accessed August 29, 2012. 2. Joint Review Committee on Education in Radiologic Technology. Standards for an accredited educational program in radiation therapy. www.jrcert.org/sites/jrcert/uploads /documents/2011_Standards/Standards_2011-Radiation _Therapy.pdf. Effective January 1, 2011. Accessed August 29, 2012. 3. Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012;307(22):2400-2409.
